HESI Case Study: Burns - Questions & Answers

HESI Case Study: Burns - Questions & Answers Which action is included when a Level I disaster is declared? All local hospitals prepare to receive casualties. Which action should the nurse implement to help these family members cope with this tragedy? Designate specific family areas that are staffed with counselors. EMS personnel triage clients, with multiple casualties noted. Which action should the triage nurse implement first? Place a disaster tag securely on each victim. Triage determines in what order a client is seen by a healthcare provider (HCP). Which of the following clients would the nurse identify with a red tag? -A client whose vital signs include respirations at 22 breaths/min , pulse at 120 beats/min, and blood pressure at 85/52 mmHg. -A client with a pulsating femur wound. -A client with full thickness burns over 50% of the body. Which triage category should the nurse assign to James? Priority 1, Color Red. The client has many physical, emotional, and psychosocial needs. Which intervention is most important for the nurse to implement upon admission? Establish and maintain an open airway. The nurse should document which percentage of body surface? 45% James grimaces in pain as the nurse assesses James' red and blistered wounds that are affecting his epidermis and dermis. Based on this assessment, which finding best describes the James' burns? Partial thickness or second degree burns. Based on the nurse's understanding of the Parkland Formula, which rate correctly describes the time the fluid is given to the client? The nurse administers the first half of the fluid from the time the burn occurred over 8 hours, and the second half over the following 16 hours. Which action should the nurse take? Inform the officer that he must first speak to James' parents. The police officer then asks to see James' ED medical record. Which action should the nurse take concerning this request? Allow the police officer access to the requested medical records. Burn clients who surpass 20% Total Body Surface Area (TBSA) have massive shifts of fluid and electrolytes from intravascular to extravascular spaces, which can lead to cardiovascular collapse. Which assessment relates most directly to a diagnosis of Curling's ulcer? Assess the gastric aspirate for pH and blood the color of coffee grounds. Fluid replacement is noted to be ideal if